Family History Questionnaire

If you have been advised by the surgery to submit a Family History Questionnaire please use this form.

Family History Questionnaire

Family History Questionnaire

About You

Have you had cancer or polyps yourself?

If you or a close relative have previously been referred to a clinical genetic department to discuss the family history of cancer we may already have the information we need. Please give their details below

Completing the Family history questionnaire

Why have I been given a family history questionnaire?
This may be because there are several cancers in your family or because you or a relative has had cancer at a young age. In most families, cancer occurs by chance and the risk to other people in the family is no different to that of the general population. However a small proportion of cancers (less than 10%) are due to an inherited risk. To determine if your family history is due to inherited risk, we need to gather detailed information.

How is the information I give used?
We will use this information to assess your personal risk for cancer and advise your doctor on appropriate screening for you (if needed). We will let you know if genetic testing may be helpful in your family and help provide advice for other members of your family.

How should I fill in the form?
Please fill in the form giving as much information as possible about your blood relatives, including those who have not had cancer. If you need extra space you can continue on a separate sheet if necessary.

What if I don't know all the details?
If you do not know all the information, perhaps someone else in the family would be able to help you. If this is not possible please do not worry, just provide the information that you can.

    Names: If a relative has changed their name (e.g due to marriage or divorce) please give any previous names.
    Address: If you do not know a relatives address please write down the town or city they lived in when they had cancer.
    Dates of birth/death: If exact dates of birth and death are not known, then please put approximate dates and ages.
    Types of cancer: We need to know where in the body someone had cancer (e.g breast, bowel, lung) or if they had bowel polyps. If you do not know, write 'unknown cancer'.

If I give you my relatives details will you contact them directly?
We will not contact your relatives directly, but will send you a consent form to pass on to your relatives requesting their permission to access information about their cancer if you are happy to do so.

What happens next?
Our team of genetic counsellors and consultants will assess your questionnaire to see if your risk of cancer is increased.

    If your risk is no different to the general population we will write to you to reassure you that extra screening is not likely to be beneficial for you.
    We may need more details about the cancers in your family from medical records. We can access this automatically from relatives who are deceased but we need consent from relatives who are living. If consent is not available we can still advise you but our advice may be less accurate.

Once we have obtained all the information we will either write to you or arrange an appointment for you to discuss this with one of our genetic doctors or counsellors. We aim to offer you advice within 18 weeks of receiving your referral and completed form.

Questions? Please telephone our cancer triage nurses on 01865 225327 for help.

More information on what to expect from a cancer genetic referral is available from the leaflet 'The Cancer Genetic Service; information for people who have been referred to the Cancer Genetic Service'. This can be found on the Oxford University Hospitals website (

Your Family History 01. Your parents and children

Your Family History 02. Your brothers and sisters, full or half

Half through:
Half through:
Half through:

Your Family History 03. Your mother's parents, brothers and sisters

Half through:
Half through:

Your Family History 04. Your father's parents, brothers and sisters

Half through:
Half through:

Your Family History 05. Other affected relatives

Please say exactly how each person is related to you, e.g:

    Mother's mother's father (not 'great grandfather' as this could also be your mother's father's father, or father's mother's father etc).
    Mother's sister's daughter (please do not say 'cousin').

Jewish Ancestry

An inherited predisposition to cancer may be more common in Jewish populations, do you have any Jewish Ancestry?

Your medical history

Have you had any operations?
Was it for cancer?
Do you have other significant health problems?
Have you or anyone in your family ever suffered from a blood clot?
Have you had any cancer screening such as mammography or colonoscopy?

For female patients

Do you/did you breast feed your children?
Do/did you use the oral contraceptive pill?
Do/did you use HRT?
Which type of HRT were/are you taking?
Are you in the menopause?

Additional information